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Is cancer due mostly to “bad luck”?

One of the more difficult conversations to have with a patient as a cancer doctor occurs when a patient, recently informed of her diagnosis of, for example, breast cancer, asks me, “Why did I get this? What caused it?” What almost inevitably follows is an uncomfortable conversation in which explanations of the multiple known causes of breast cancer do not satisfy the patient. The reason, of course, is because when a patient asks, “What caused it?” she doesn’t mean what causes breast cancer in general or in statistical terms. Rather, she means, what caused my breast cancer? It’s a question that can only occasionally be answered. For instance, if it’s lung cancer and the patient is a smoker, then it was almost certainly smoking that caused the cancer, because lung cancer is a relatively rare cancer in the absence of smoking. In the case of breast cancer, contrary to the prevailing belief that leads women with breast cancer to be puzzled about how they could get it when there’s “no cancer” in their families, only around 5-10% of cases have a familial or genetic component. That means that around 90% of breast cancers are what we call “sporadic,” which means that we can’t identify a specific cause. Or, as I like to say, “We just don’t know.” Worse, in the case of breast cancer, the environmental factors we know about appear to contribute modestly at best to the risk of cancer. (More on this later.)

Understandably, patients hate hearing “We just don’t know,” some vague handwaving about genes, and that there is nothing that we know of that they did that caused their cancer. People—including oncologists—really don’t like the concept of “sporadic” cancer, mainly because humans crave explanation. The default assumption is that everything must happen for a reason and there must be a cause for every disease or cancer. Perhaps the most ridiculously emphatic statement of this that I’ve encountered thus far comes from (who else?) über-quack Mike Adams when he heaped contempt on the idea of sporadic disease as “spontaneous disease.” He did this in the context of a story describing how, after Dr. Mehmet Oz had followed recommended care and undergone screening colonoscopy to look for polyps, he was shocked that he actually had some. This led Adams, in his usual inimitable fashion, to construct a straw man so massive that it could be seen from space when he set it on fire, declaring that “colon polyps, in other words, appear without any cause!” and that “mainstream medicine…believes in the theory of ‘spontaneous disease’ that ‘strikes’ people at random.”

Not exactly.

On the other hand, there is a lot of randomness in disease, not just cancer, as hard as it is for Mike Adams, or anyone to accept. Just because there is a varying amount of randomness in who gets a disease does not mean that mainstream medicine claims there is no cause to these diseases. Rather, for diseases like cancer, it’s a stochastic process, meaning that chance can play a role—sometimes a big role—in determining who gets sick. Indeed, just last week there was more evidence supporting this idea published in Science. Unfortunately, much of the mainstream press coverage presented the message of the paper a bit too simplistically. Even more unfortunately, it was the authors who encouraged this, as did the Johns Hopkins University press release about the study, which was entitled “Bad Luck of Random Mutations Plays Predominant Role in Cancer, Study Shows“. Yes, I groaned when I read this title.
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Posted in: Basic Science, Cancer, Epidemiology, Science and the Media

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Acupuncture for Withdrawal Symptoms in Critically Ill Infants

weebleswobble

Like acupuncture, Weebles wobble, but they don’t fall down.

The practice of medicine, particularly our pharmaceutical and surgical interventions, involves a constant struggle between risk and benefit. If the physiology or anatomy of the human body is altered, even with the best of intentions, there is always a potential downside. There are certainly instances where the risk to benefit ratio is extremely favorable or unfavorable and the right recommendation is obvious, and unfortunately there are times when it isn’t entirely obvious what the next step should be. But there has been a trend of steady progress in regards to improved safety and efficacy over the past several decades.

The treatment of pain has of late been one of those areas where the picture is becoming a bit less cloudy. We are learning more and more about the potential negative outcomes related to the long term use of opioid medications, such as physical dependence, addiction and even chronic pain. The way that these drugs have been prescribed in many patients has caused more harm than expected, and in some instances more hurt than help. Doctors generally strive to alleviate pain and suffering but, once again, good intentions don’t decrease risk.

In the neonatal and young infant population, the management of pain has had a rocky history. I’ve written about pediatric pain in the past, in particular the potential difficulties in managing acute pain. I won’t go into detail (read my prior post), but we have truly come a long way since the days of performing major surgery on newborns without any analgesia at all. There are areas where we need to do better, however. Children are still less likely than adults to be adequately treated for pain.

But things have improved. And as more children receive appropriate management for pain, the side effects of that management must increasingly be dealt with by healthcare professionals, the patients and their families. One of the issues that is typically observed and managed in neonatal and pediatric intensive care units is physical dependence and the subsequent occurrence of withdrawal symptoms.
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Posted in: Clinical Trials

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Detox: What “They” Don’t Want You To Know

Happy New Year! Today’s post was some old material, dusted off, repackaged, and updated for 2015.

New Year, New You, right? We’re just into 2015, and you’ve resolved to finally get serious about your health. Starting today. But first need to cleanse yourself, eliminating last year’s lifestyle and dietary sins. You’ve seen the ads and the Facebook links, all suggesting you need a “detox”, “cleanse” or “flush” to be healthy. Supplements, tea, homeopathy, coffee enemas, ear candles, and footbaths promise you a detoxified body. Amazon has entire detox and cleansing categories in supplements and books. The descriptions all suggest detoxing will deliver a renewed body and better health – it’s only seven days and $49.95 away. Dr. Oz has several detox plans – you just need to decide which one. The local naturopath sells detoxification protocols, including vitamin drips and chelation. Even your pharmacy probably has a wall of products for sale. Wouldn’t a purification from your sins of 2014 be a good idea to start the year? Unfortunately, there’s something very important that detox promoters aren’t telling you. (more…)

Posted in: Health Fraud, Herbs & Supplements, Homeopathy, Naturopathy

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Glyphosate – The New Bogeyman

3D model of the molecular structure of glyphosate.

3D model of the molecular structure of glyphosate.

There is an ideological subculture that is motivated to blame all the perceived ills of the world on environmental factors and corporate/government malfeasance. Often this serves a deeper ideological drive, which can be anti-vaccine, extreme environmentalism, or anti-GMO. The latest environmental bogeyman making the rounds is glyphosate, which is being blamed for (you guessed it) autism.

Glyphosate is the active ingredient in the herbicide Roundup. It has been widely used for about 40 years, and with the introduction of GM crops that are Roundup resistant, its use has increased significantly in the last 20 years. It has therefore become a popular target for anti-GMO fearmongering.

Glyphosate is one of the least toxic herbicides used. It inhibits the enzyme 5-enolpyruvylshikimic acid-3-phosphate synthase which interferes with the shikimic pathway in plants, resulting in the accumulation of shikimic acid in plant tissues and ultimately plant death. The enzyme and pathway do not exist in animals, which is why toxicity is so low. Still, chemicals can have multiple effects and so toxicity needs to be directly measured and its epidemiology studied. (more…)

Posted in: Public Health

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The Health Benefits of Moderate Drinking

A Book of Verses underneath the Bough,
A Jug of Wine, a Loaf of Bread–and Thou
Beside me singing in the Wilderness–
Oh, Wilderness were Paradise enow!”

- The Rubaiyat of Omar Khayyam

 1024px-A_glass_of_red_wine

Alcoholic beverages have always inspired strong opinions pro and con. Omar Khayyam included wine in his vision of Paradise; Carrie Nation took a hatchet to saloons. Humans have been drinking alcoholic beverages for at least 12,000 years. In earlier eras beer and wine were dietary staples that provided essential calories and were safer to drink than water. Early cultures worshipped wine deities; today, some religions ban all forms of alcohol while others embrace red wine as an essential part of a holy sacrament. Alcoholic beverages are widely used as an accompaniment to meals and as a social lubricant (as Ogden Nash put it, “Candy is dandy, but liquor is quicker”). Prohibition didn’t work.

It’s always good when opinions can be backed up by scientific evidence. Those who drink, especially wine lovers, can bolster their personal preference with the evidence from recent studies showing that moderate alcohol consumption prolongs life and improves health in various ways. Those who prefer not to drink are being told they can get the same benefits from resveratrol, a component of red wine. Just how good is the evidence, and what does it really tell us? (more…)

Posted in: Nutrition

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Stem cells versus Gordie Howe’s stroke, part 2

Gordie-Howe

Another Christmas has come and gone, surprisingly fast, as always. I had thought that it might make a good “last of 2014″ post—well, last of 2014 for me, anyway; Harriet and Steve, at least, will be posting before 2014 ends—to do an end of year list of the best and worst of the year. Unfortunately, there remains a pressing issue that doesn’t permit that, some unfinished business, if you will. I’m referring to a story I commented on last week, specifically the credulously-reported story of how 86-year-old hockey legend Gordie Howe is doing a lot better after having undergone an experimental stem cell therapy for his recent stroke. As you might recall at the time, I saw a lot of holes in the story. It turns out that over the last week there have been developments that allow me to fill in some of those holes. Unfortunately, other holes still remain.

First, a brief recap is in order (You can click here for a more detailed timeline). Gordie Howe suffered a massive stroke on October 26, leaving him hemiplegic and with serious speech impairment. Since then, judging from various media reports, he has been slowly improving, although not without significant setbacks. We also know that Howe suffers from significant dementia. Out of the blue, a press release issued on December 19 by the Howe family announced that on December 8 and 9, Gordie Howe “underwent a two-day, non-surgical treatment at Novastem’s medical facility. The treatment included neural stem cells injected into the spinal canal on Day 1 and mesenchymal stem cells by intravenous infusion on Day 2.” His response was described as “truly miraculous,” although, as I pointed out in my post, it’s not clear exactly what “miraculous” meant, given conflicting contemporaneous news accounts before the Howe family press release, particularly his hospitalization from December 1 to 3 for a suspected stroke that turned out to be dehydration.

I noted a number of problems with the story, the first of which is that Howe was clearly not eligible for the clinical trial offered by Stemedica, a company in San Diego that manufactured the stem cells used. Another glaring issue was my inability to locate any description of an actual clinical trial for stroke offered by Novastem. I could find no such trial listed in ClinicalTrials.gov, and you, our intrepid readers, searched the registry maintained by the Mexican Federal Commission for the Protection Against Sanitary Risk (COFEPRIS) and were not able to find any registered clinical trials for stroke being carried out by Clínica Santa Clarita, the clinic Novastem operates. What you, our intrepid readers, did find were trials of stem cells for:

I did the search again over the weekend, and there were no further trials that I could find.
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Posted in: Clinical Trials, Medical Ethics, Science and the Media

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Acupuncture Odds and Ends

I’m cheating. No, I’m recycling. ‘Tis the season to have to no time to get anything done. Since I know none of you pay attention to the blog of at the Society for Science-Based Medicine and I have no time with work and the holidays to come up with new material, I am going to collect and expand on the entries on acupuncture I wrote from SfSBM. Anything I write really is worth reading twice. I really need to make my multiple personality disorder work for me, but the Goth cowgirl persona is a luddite at best, so you are stuck with the over -extended ID doctor. Here goes.
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Posted in: Acupuncture, Traditional Chinese Medicine

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TV Doctors Give Unreliable Recommendations

DrOzMiracleIt’s always preferable to have objective empirical evidence to inform an opinion, rather than just subjective impressions. Confirmation bias will make it seem as if the facts support your opinion, even when they don’t. Of course, when objective evidence (such as published studies) does seem to support your position, you still have to keep your critical shields up. Confirmation bias can still kick in, resulting in cherry-picking favorable evidence, finding fault with studies whose conclusions you don’t like, and too-easily accepting those that confirm your position.

I therefore had to be careful in evaluating the following study from the BMJ, because it nicely confirms what I and many others here at SBM have been saying for years – recommendations made by TV doctors, particularly Dr. Oz, are unreliable and insufficiently based on evidence.

This was a prospective study that:

…randomly selected 40 episodes of each of The Dr Oz Show and The Doctors from early 2013 and identified and evaluated all recommendations made on each program.

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Posted in: Science and the Media

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The Marvelous Dr. Mütter

The Mütter Museum in Philadelphia has a marvelous collection of human bones, surgical specimens, monsters in jars, and medical memorabilia. It holds attractions for everyone, from the jaded medical professionals who thought they’d seen it all to the coveys of youngsters who compete to point out the grossest items to their friends, from the student of history to the connoisseur of the macabre. There is an enormous megacolon said to look like a sandworm from Dune, a plaster cast of the famous Siamese twins Chang and Eng along with their actual preserved conjoined livers, a collection of bizarre swallowed objects, an iron lung, a tumor removed from president Grover Cleveland’s jaw while he was in office, a shocking assortment of deformed fetuses…the list goes on.

I knew about the museum and greatly enjoyed visiting it, but I didn’t know anything about Dr. Mütter himself until I read a delightful new book by Cristin O’Keefe Aptowicz , Dr. Mutter’s Marvels: A True Tale of Intrigue and Innovation at the Dawn of Modern Medicine. I learned that the good doctor was every bit as marvelous as his museum, and the book took me on a fascinating trip back to the medicine of the early 1800s that made me better appreciate all that modern medicine has accomplished.

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Posted in: Book & movie reviews, History, Surgical Procedures

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